Unraveling the risk factors for spontaneous intracerebral hemorrhage among West Africans

Abstract

ObjectiveTo characterize risk factors for spontaneous intracerebral hemorrhage (sICH) occurrence and severity among West Africans.MethodsThe Stroke Investigative Research and Educational Network (SIREN) study is a multicenter case-control study involving 15 sites in Ghana and Nigeria. Patients were adults ≥18 years old with CT-confirmed sICH with age-, sex-, and ethnicity-matched stroke-free community controls. Standard instruments were used to assess vascular, lifestyle, and psychosocial factors. Factors associated with sICH and its severity were assessed using conditional logistic regression to estimate odds ratios (ORs) and population-attributable risks (PARs) with 95% confidence intervals (CIs) for factors.ResultsOf 2,944 adjudicated stroke cases, 854 were intracerebral hemorrhage (ICH). Mean age of patients with ICH was 54.7 ± 13.9 years, with a male preponderance (63.1%), and 77.3% were nonlobar. Etiologic subtypes of sICH included hypertension (80.9%), structural vascular anomalies (4.0%), cerebral amyloid angiopathy (0.7%), systemic illnesses (0.5%), medication-related (0.4%), and undetermined (13.7%). Eight factors independently associated with sICH occurrence by decreasing order of PAR with their adjusted OR (95% CI) were hypertension, 66.63 (20.78–213.72); dyslipidemia, 2.95 (1.84–4.74); meat consumption, 1.55 (1.01–2.38); family history of CVD, 2.22 (1.41–3.50); nonconsumption of green vegetables, 3.61 (2.07–6.31); diabetes mellitus, 2.11 (1.29–3.46); stress, 1.68 (1.03–2.77); and current tobacco use, 14.27 (2.09–97.47). Factors associated with severe sICH using an NIH Stroke Scale score >15 with adjusted OR (95% CI) were nonconsumption of leafy green vegetables, 2.03 (1.43–2.88); systolic blood pressure for each mm Hg rise, 1.01 (1.00–1.01); presence of midline shift, 1.54 (1.11–2.13); lobar ICH, 1.72 (1.16–2.55); and supratentorial bleeds, 2.17 (1.06–4.46).ConclusionsPopulation-level control of the dominant factors will substantially mitigate the burden of sICH in West Africa.

Insights in the pathophysiology of haemorrhagic strokes in a sub‐Sahara African country, an epidemiological and MRI study

“…Those findings concur with a recent meta‐analysis where ApoE‐e2/e4 phenotypes were only found to be associated with lobar ICH in black individuals when propensity score matching for hypertension burden was not included in the model, highlighting the major role of hypertension in the pathophysiology [54]. Our data also concur with recent epidemiological data from West Africa, where hypertension was involved in over 80% of ICH, whereas CAA was involved in less than 1%, even if the lack of MRI brain imaging in that study probably underestimated the CAA burden [43].…”

“…Similarly, age of first ICH stroke in our Belgian cohort matches results from large epidemiological studies and trials on ICH in HIC [40,41]. Second, a greater proportion of deep white matter supra‐tentorial haematomas was found parallel studies in Burkina Faso, Cameroon, DRC, Congo, Nigeria and Ethiopia [9,34‐39,42,43]. Third, ICH mortality rate was similar in Guinea and cohorts from Burkina Faso, DRC and Nigeria that also showed over 30% mortality rates [34‐36,38,42,44], while ICH mortality rates in Belgium corresponded to mortality levels in previous large trials on ICH in HIC [40,41].…”

“…56 Our data also concur with recent epidemiological data from West Africa , where hypertension was involved in over 80% of ICH, whereas CAA was involved in less than 1%, even if the lack of MRI brain imaging in that study probably underestimated the CAA burden. 43 Another major finding from this study is the extremely severe prognosis of ICH in SSA. This poor outcome of ICH…”

“…40,41 Second, a greater proportion of deep white matter supra-tentorial hematomas was found parallel studies in Burkina Faso, Cameroon, DRC, Congo, Nigeria and Ethiopia. 9,[34][35][36][37][38][39]42,43 Third, ICH mortality rate was similar in Guinea and cohorts from Burkina Faso, DRC and Nigeria that also showed over 30% mortality rates, [34][35][36]38,42,44 while ICH mortality rates in Belgium corresponded to mortality levels in previous large trials on ICH in HIC. 41,45 The younger age of onset of ICH in Guinea and larger hematoma volume initially suggested a different pathophysiology for ICH in Guinea than in Belgium.…”

Stroke in Africa: profile, progress, prospects and priorities

“…In the SIREN study, the aetiology of ICH was classified using the structural lesion, medication, amyloid angiopathy, systemic and/or other disease, hypertension, undetermined (SMASH-U) algorithm 155 . Using this method, the most common aetiology was hypertension (80.9%); less common were structural vascular anomalies (4.0%), cerebral amyloid angiopathy (0.7%), systemic illnesses (0.5%) and medication-related aetiologies (0.4%) 156 . Aetiology remained undetermined in 13.7% of participants.…”